A General Practice of Therapy

Finally feeling hopeful about Mental Health Research

You might remember, about 5 years ago the National Institute of Mental Health in the U.S. finally said enough! This whole idea of clustering symptoms of mental ill health into diagnostic categories was a great idea, but it just hasn’t got us anywhere.

I remember my heart lifting and a cheer tried to escape but was quickly crushed by what I read next. They were now going to focus on neural pathways. So instead say of studying PTSD, anxieties and phobias say, as separate entities, they were going to look at fear pathways, with modern laboratory techniques and neuroimaging, and I felt my heart sink. I think because what I read didn’t really sound like a change in paradigm, or how we think about human suffering, just a new thing to look at with old eyes.

Ive checked in now and then since then and have not felt my spirits lifted.

So, this morning, after a week of frustrating conversations with the old old paradigm I thought I’d check in again. Now this is not new, it’s a talk from 2013, and it may have been on the NIH website for some time, but it lifted my spirits. I think there’s still a bit of blindness from looking through the medical model, but in relation to my frustrations about psychotherapy research I think it’s fantastic.

I said to Rob, “you should listen to this” and he said “give me the short version!” So here goes.

In the old paradigm when we make a mental health diagnosis, we are making it with symptom clusters, and that’s like saying “You have a headache disorder, or stomachs ache disorder” without going any further, and then giving that diagnosis the same authority that we might give diabetes. And that really isn’t any more advanced than the ancient Greeks description of melancholia.

The major problem though, is that with all the modern techniques for neuroimaging, for structural and functional analyses of the brain, the findings don’t map on very well to the disorders. I’ve often thought it will turn out to be like diabetes, which was described early on in relation to excessive urination, but when we finally discover some biochemical cause, we have two distinct entities, diabetes mellitus, and diabetes insipidus, which are so dramatically different in their cause and physiology that had they been discovered biochemically would never have been given the same name.

And that seems to be the problem. That DSM has given a whole lot of heterogeneous symptoms the same name, so no wonder we haven’t come up with a specific diagnostic test or specific treatment. From a paper titled “The drug hunters” the report is that “On average, a marketed psychiatric drug is efficacious in approximately half of the patients who take it.” He presumes that those are the people who have the thing wrong that the drug treats.. (a bit of a stretch but an interesting idea)

(At this point I want to caution myself about this seductive pull to turn the mysterious unfathonableness of the human condition into a simple machine, but for the sake of the short version I will press on.)

So RDoC, stands for Research Domain Criteria. The statement in RDoC’s strategic plan states, “Develop for research purposes new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures.”

There are four components.

The first component Is to identify these fundamental components that may span multiple disorders. So they look at circuits in the brain. Circuits responsible for dealing with threat, looking for food, memory, that kind of thing, and you start to see how lots of these circuits will be at play in different ways in different people who might all say fall under the current umbrella of depression.

The second component is “To determine the full range of variation from normal to abnormal.” This is very cool I think, because they are starting to see all symptoms on the spectrum of normal, and that there has been some adaptive behavior say that has taken a normal behavior to extreme. Watch the video for some useful observations about Schizophrenia and Bipolar. I think clinicians have long seen symptoms on a spectrum of normal, but for researchers to finally get this is a huge step forward I think.

The third component is to integrate genetic, neurobiological, behavioral, environmental, and experiential components, so that the complexity of the human experience is not lost in the science. And they are not just giving lip service to that complexity the way the “biopsychosocial model” did.

And the fourth component is to develop some measure, which might just start with what can be measured and seeing what that lines up with. They seem to be starting from a position of not knowing, and being willing to discover, even if it’s at odds to what they think they know.

The other heartening thing is that they are looking at neurodevelopment. Acknowledging that things that happen to the developing human have an impact at many levels, and understanding more about that impact can inform what to do about it, both with treatment and prevention. They are also looking at the impact of environment, both positive and negative.